Nilgun Cinar

A Multicenter Study of 1144 Patients with Cerebral Venous Thrombosis: The VENOST Study

BACKGROUND Based on a number of small observational studies, cerebral venous sinus thrombosis has diverse clinical and imaging features, risk factors, and variable outcome. In a large, multicenter cerebral venous thrombosis (VENOST) study, we sought to more precisely characterize the clinical characteristics of Caucasian patients. METHODS All data for the VENOST study were collected between the years 2000 and 2015 from the clinical follow-up files. Clinical and radiological characteristics, risk factors, and outcomes were compared in terms of age and sex distribution. RESULTS Among 1144 patients 68% were women, and in older age group (>50 years) male patients were more prevalent (16.6% versus 27.8%). The most frequent symptoms were headache (89.4%) and visual field defects (28.9%) in men, and headache (86.1%) and epileptic seizures (26.8%) in women. Gynecological factors comprised the largest group in women, in particular puerperium (18.3%). Prothrombotic conditions (26.4%), mainly methylenetetrahydrofolate reductase mutation (6.3%) and Factor V Leiden mutation (5.1%), were the most common etiologies in both genders. 8.1% of patients had infection-associated and 5.2% had malignancy-related etiology that was significantly higher in men and older age group. Parenchymal involvement constitutively hemorrhagic infarcts, malignancy, and older age was associated with higher Rankin score. Epileptic seizures had no effect on prognosis. CONCLUSIONS Clinical and radiological findings were consistent with previous larger studies but predisposing factors were different with a higher incidence of puerperium. Oral contraceptive use was not a prevalent risk factor in our cohort. Malignancy, older age, and hemorrhagic infarcts had worse outcome.

Eye-related visual hallucinations: consider 'Charles Bonnet syndrome'.

The Charles Bonnet Syndrome (CBS) is typically characterized by visual hallucinations in elderly people without cognitive defects. This article presents the case of an 80-year-old male patient with a one-year history of visual hallucinations, secondary to glaucoma, in both eyes. Neither a dopamine agonist nor cholinesterase inhibitor therapy improved his symptoms. In this case, the hallucinations were gradually improved after administration of a GABAergic drug, pregabalin, for diabetic polyneuropathy. Placebo-controlled clinical trials would be needed to support this effect of pregabalin, as suggested by this association.

Effects of Anthropometric Factors on Nerve Conduction An Electrophysiologic Study of Feet

BACKGROUND Previous studies have shown that age, sex, and body mass index (BMI) affect the amplitude of sensory nerve action potentials (SNAPs), but the total effects of multiple factors and the most prominently affected nerves have not been elucidated. We systematically investigated the effects of these factors on motor and sensory nerves of the feet. METHODS The amplitude, latency, and conduction velocity of compound muscle action potential (CMAP), SNAP, and mixed nerve action potential (MNAP) of the posterior tibial, calcaneal, distal posterior tibial, medial and lateral plantar, and sural nerves were measured in 30 healthy individuals (60 feet). The effects of age, sex, height, and BMI on each nerve were estimated by correlation and linear regression analyses. RESULTS The amplitude of posterior tibial CMAP and distal posterior tibial MNAP decreased with BMI. The amplitude of medial plantar MNAP and sural SNAP decreased with height. The conduction velocity of calcaneal SNAP and distal posterior tibial and lateral plantar MNAP decreased with height and BMI. The conduction velocity of medial plantar MNAP decreased only with height. The latency of posterior tibial CMAP increased with age and height. The latency of lateral plantar CMAP and calcaneal SNAP increased with height. The latency of lateral plantar MNAP increased with BMI. CONCLUSIONS The effects of age, sex, height, and BMI in foot nerve conduction studies are not identical. Height and BMI were shown to strongly affect motor, sensory, and mixed nerve conduction. Further investigations are needed.

Balance in essential tremor during tandem gait: Is the first mis-step an important finding?

Essential tremor (ET) is the most commonly diagnosed movement disorder. ET may cause substantial loss of motor skills and balance with advanced age. We compared abnormalities in tandem gait with daily activity and Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS) scores in 90 ET patients. All patients performed a 15-step tandem three times. The mean of first mis-steps was accepted as the tandem index (TI). The mean age was 61.4 ± 17 years; the mean duration of tremor was 6.7 ± 4 years; and there were 36 men and 54 women. There was no significant difference for age or sex between patients and controls. Head (24.6%), jaw (5.5%), voice (11%), and tongue tremors (1.5%) were identified in ET patients. Rest (2.5%), postural (95%), and kinetic tremors (54%) were detected in the upper extremities. Postural tremor was found in the lower extremities of 5%. The mean TI was 8.3 ± 4 (median, 8) in ET patients, and 10.6 ± 3.9 (median, 10) in controls (p=0.04). Correlation analysis of TI and FTMTRS scores showed tandem gait was significantly correlated with age, total tremor score, postural and kinetic extremity tremor, writing, drawing, pouring, feeding, and working scores. Linear regression showed a significant effect of age and FTMTRS score on TI. The decrease in balance control is apparent with advancing age. Balance disorders were more pronounced in ET patients. Although first mis-step in tandem gait is not as detailed as dynamic balance tests, it can be a simple method for detecting balance disorders.

Gender differences in older adults with chronic migraine in Turkey

Chronic migraine is a growing and disabling subtype of migraine with different risk factors and clinical features, even in older adults. We sought to define and differentiate clinical features of chronic migraine in older adults. We also aimed to compare major clinical features of chronic migraine in older adults with those in younger people of both sexes.

Distinguishing Depressive Pseudodementia from Alzheimer Disease: A Comparative Study of Hippocampal Volumetry and Cognitive Tests

Background and Aim: Depressive pseudodementia (DPD) is a condition which may develop secondary to depression. The aim of this study was to contribute to the differential diagnosis between Alzheimer disease (AD) and DPD by comparing the neurocognitive tests and hippocampal volume. Materials and Methods: Patients who met criteria of AD/DPD were enrolled in the study. All patients were assessed using the Wechsler Memory Scale (WMS), clock-drawing test, Stroop test, Benton Facial Recognition Test (BFRT), Boston Naming Test, Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS). Hippocampal volume was measured by importing the coronal T1-weighted magnetic resonance images to the Vitrea 2 workstation. Results: A significant difference was found between the AD and DPD groups on the WMS test, clock-drawing test, Stroop test, Boston Naming Test, MMSE, GDS, and left hippocampal volume. A significant correlation between BFRT and bilateral hippocampal volumes was found in the AD group. No correlation was found among parameters in DPD patients. Conclusions: Our results suggest that evaluation of facial recognition and left hippocampal volume may provide more reliable evidence for distinguishing DPD from AD. Further investigations combined with functional imaging techniques including more patients are needed.

What is the impact of electromagnetic waves on epileptic seizures

Background The effects of electromagnetic waves (EMWs) on humans and their relationship with various disorders have been investigated. We aimed to investigate the effects of exposure to different frequencies of EMWs in various durations in a mouse epilepsy model induced by pentylenetetrazole (PTZ). Material/Methods A total of 180 4-week-old male mice weighing 25–30 g were used in this study. Each experimental group consisted of 10 mice. They were exposed to 900, 700, 500, 300, and 100 MHz EMWs for 20 hours, 12 hours and 2 hours. Following electromagnetic radiation exposure, 60 mg/kg of PTZ was injected intraperitoneally to all mice. Each control was also injected with PTZ without any exposure to EMW. The latency of initial seizure and most severe seizure onset were compared with controls. Results The shortest initial seizure latency was noted in the 12-hour group, followed by the 700 MHz. The mean initial seizure latencies in the 2-hour EMW exposed group was significantly shorter compared to that in the 12- and 20-hour groups. There was no significant difference between 12- and 20-hour EMW exposed groups. There was a significant difference between control and 2- and 10-hour EMW exposed groups. No statistically significant differences were noted in mean latencies of the most severe seizure latency, following 20-, 12-, and 2- hour EMW exposed groups and control groups. Conclusions Our findings suggest that acute exposure to EMW may facilitate epileptic seizures, which may be independent of EMW exposure time. This information might be important for patients with epilepsy. Further studies are needed.

From Lithium Intoxication to Lung Cancer: A Woman's Diagnostic Journey.

To the Editor: Sometimes, the suspicion of lithium intoxication may cause an “intoxication” in clinical diagnosis. Case report. Ms A, a 47-year-old woman with bipolar affective disorder (of multiple etiologies, including those conforming to ICD-10 and DSM-IV criteria) who had been treated with lithium, was admitted to our emergency department in December 2009 for myalgia, fever, and generalized weakness. Five years prior, she attempted suicide by jumping from the fifth floor. She had spinal decompression from T12–L3 as well as an instrumented reconstruction with platinum rods. Because of the spinal cord injury, she was using a catheter to empty the bladder. Her body temperature was 37.5°C. An x-ray study of the chest showed an infiltration into the left apex. Urinalysis revealed trace bacteria, 9–11 white blood cells per high power field. The plasma lithium concentration was 2 mmol/L, and the creatinine level was 0.8 mg/dL. The erythrocyte sedimentation rate was 80 mm/h. The 24-hour urine amount was 6000–7000 mL. In light of these findings, it is thought that lithium toxicity developed due to urinary or pulmonary infection. Lithium was stopped after the possibility of intoxication was identified. Olanzapine was started at the dose of 10 mg/d as a mood stabilizer. Because the patients general condition was poor, the lithium could not be restarted and the diagnosis of intoxication could not be confirmed. The muscle strength in both of the upper extremities was normal. In the lower extremities, paraplegia with brisk deep tendon reflexes and Babinskis sign was detected bilaterally. These findings were considered sequelae of the prior spinal cord damage. Nerve conduction studies identified a serious decrease in the amplitudes in the lower extremities, suggesting smotor axonal damage. The cerebrospinal fluid (CSF) analysis showed 100 white cells/mm3, 315 mg/dL protein, and glucose level within normal limits. In light of these findings, an acute motor axonal neuropathy was diagnosed. Ms A received intravenous immunoglobulin (0.4 mg/kg/d) for 5 days. No clinical improvement was seen. The second CSF analysis showed 200 white cells/mm3, 823 mg/dL protein, and glucose level within normal limits. The spine was investigated with magnetic resonance imaging (MRI). Because thoracal epidural metastatic lesions were detected in spinal MRI, the cerebral MRI was established for research of spreading. It showed multiple metastatic lesions in brain parenchyma as well (Figure 1). Thoracic computed tomography (CT) showed a lung mass as the primary focus (Figure 2). Biopsy demonstrated lung adenocarcinoma. Figure 1 Cerebral Magnetic Resonance Imaging (MRI) Scans Showing Multiple Metastatic Lesionsa Figure 2 A Coronal Image From the Computed Tomography Scan Demonstrating a Left-Sided Apical Pulmonary Tumor In this patient, our first diagnosis was chronic lithium intoxication. Lithium is a mood-stabilizing agent commonly used for the treatment of bipolar disorder and it has a narrow therapeutic window from 0.6 to 1.5 mmol/L. Risk factors for lithium intoxication include drug interactions, infection, and dehydration.1 Our second diagnosis was acute motor axonal neuropathy. Acute motor axonal neuropathy is a known variant of Guillain-Barre syndrome with a clinical course that includes motor paralysis, hyporeflexia, albuminocytological dissociation in CSF, and finding of axonal involvement on nerve conduction study.2 Intravenous immunoglobulin and plasmapheresis have also been suggested for acute motor axonal neuropathy, as well as for Guillain-Barre syndrome.3 But our case did not show a response to intravenous immunoglobulin. Because of the failure to improve despite intravenous immunoglobulin treatment, the patients prior spine surgery history, persistent abnormal CSF findings, and isolated lower extremity paresis suggestive of paraspinal lesion clued us that a spine MRI should be done immediately. We thought that lithium intoxication and sequelae findings of the former spinal injury were masking primary lung cancer, a metastatic cranial mass, and neoplastic polyradiculopathy. On the other hand, whole findings may have originated from the combination of these diseases.

Behçet’s disease as a causative factor of cerebral venous sinus thrombosis: subgroup analysis of data from the VENOST study

OBJECTIVE This study was performed to determine the rate of cerebral venous sinus thrombosis (CVST) among cases of Behçets disease (BD) included in a multicentre study of cerebral venous sinus thrombosis (VENOST). METHODS VENOST was a retrospective and prospective national multicentre observational study that included 1144 patients with CVST. The patients were classified according to aetiologic factors, time of CVST symptom onset, sinus involvement, treatment approach and prognosis. RESULTS BD was shown to be a causative factor of CVST in 108 (9.4%) of 1144 patients. The mean age of patients in the BD group was 35.27 years and 68.5% were men, whereas in the non-BD CVST group, the mean age was 40.57 years and 28.3% were men (P < 0.001). Among the aetiologic factors for patients aged 18-36 years, BD was predominant for men, and puerperium was predominant for women. The onset of symptoms in the BD group was consistent with the subacute form. The transverse sinuses were the most common sites of thrombosis, followed by the superior sagittal sinuses. The most common symptom was headache (96.2%), followed by visual field defects (38%). CONCLUSIONS BD was found in 9.4% of patients in our VENOST series. Patients with BD were younger and showed a male predominance. The functional outcome of CVST in patients with BD was good; only 12% of patients presenting with cranial nerve involvement and altered consciousness at the beginning had a poor outcome (modified Rankin Score ⩾2).

Are cerebrospinal fluid protein levels and plasma neutrophil/lymphocyte ratio associated with prognosis of Guillain Barré syndrome?

Guillain Barré syndrome (GBS) is a post-infectious acute autoimmune polyradiculopathy. Cerebrospinal fluid (CSF) total protein level and plasma neutrophil/lymphocyte ratio (NLR) are related with autoimmune response. We aimed to reach a prognostic indicator for GBS by using electrophysiological findings, protein level of CSF, and plasma NLR based on Medical Research Council (MRC) sum score data. Cases who met diagnostic criteria of GBS and followed at least six months were enrolled in the study. Nerve conduction study (NCS) and lumbar puncture were performed one week after symptom onset. Routine CSF findings and complete blood count were recorded. Plasma NLR was calculated as the ratio of neutrophil cell count to lymphocyte cell count. All patients received intravenous immunoglobulin. MRC sum scores were calculated on administration time (1st) and six months later (2nd) for evaluation of recovery. Mean values of baseline CSF protein level, NCS parameters and NLR were compared with mean scores of MRC1st and MRC2nd. Increased CSF protein levels showed negative correlation with MRC2nd scores but no correlation with NCS. Increased NLR levels were positively correlated with age, MRC2nd scores and NCS. Facial diplegia was observed in 42% of patients. A positive correlation was found between high level of NLR and MRC1st, and there was no relationship with MRC2nd. Regression analyses showed that only CSF protein level was an independent factor on both MRC1st and MRC2nd. A positive association was found between baseline data included young age high plasma NLR, low level of CSF protein and good prognosis in our study. Also a positive correlation was found between high level of NLR and baseline disability in GBS cases with facial diplegia. Calculation of NLR is an easy and inexpensive method. On the other hand it may be influenced by age and immunotherapy. Our results showed that CSF protein level is still a liable parameter for prognosis. NLR could be a candidate prognostic marker of GBS cases. Further investigations including more cases are needed.